Specialist, Health Claims

Job Description

The Specialist, Health Claims supports the financial operations of Carnival Corporation's Health Services division by performing core activities across health claims processing, accounts payable, and financial analysis. This role is responsible for the review, investigation, adjudication, and oversight of medical claims to ensure accuracy, compliance, and cost-effective claim management. The Specialist, Health Claims serves as a key liaison between case management team, healthcare providers, insurance carrier, and internal stakeholders to facilitate timely claim resolution, monitoring high-cost cases, validate supporting documentation, and maintain appropriate financial reviews.

The Specialist analyzes medical expenses, identifies discrepancies, supports reporting and trend analysis to ensure adherence to plan provisions, regulatory requirements, and organizational policies. Additionally, the position contributes to the development of claims management strategies, escalation of complex cases, and continuous improvement of claims administration processes to optimize outcomes and control healthcare cost. They are responsible for developing and maintaining complex economic models to evaluate financial impact, including the maintenance of dashboards and reports to monitor KPIs. The role will also support the development, implementation and the monitoring of department financial performance.

The role requires strong attention to detail, analytical capability, experience in medical claim management, and the ability to communicate effectively with internal teams and external providers.

This position interfaces with all brands, shipboard medical teams, shoreside health services, and external vendors supporting Carnival's global healthcare ecosystem.

Essential Functions:

MANAGEMENT OF CLAIMS

• Manage high-cost and complex medical claims, ensuring timely cost recording and closure.
• Appropriately identify and escalate high-cost or complex cases to Management.
• Oversee the complete inventory of claims, including monitoring and reporting open, pending and close claims.
• Track claim aging and follow up on unresolved invoices to ensure timely closure.
• Coordinate with providers, insurance, and third-party administrators regarding the invoice status and documentation.
• Monitor claim reserves and update financial projections as needed.
• Investigate claim discrepancies, overpayments and appeals.

MEDICAL INVOICE PROCESSING AND VALIDATION

• Review, verify and process medical invoices ensuring accuracy of patient data, diagnoses, procedure/services billed, and billing amounts. Demonstrate a strong attention to detail in the review and processing of all payments.
• Process medical reimbursement with a high level of precision, ensuring compliance with policy requirements and proper documentation.
• Ensure alignment with contracted rates, term dates, benefit eligibility, and documentation requirements.
• Identify discrepancies, overbilling, and coding errors; escalate complex cases to Finance Managing team.
• Review and approve medical invoices within delegated authorization limits, ensuring accuracy, compliance with company policies, and appropriate supporting documentation.
• Maintain compliance with internal policies, insurance guidelines, and regulatory standards.

FINANCIAL REPORTING & ANALYTICS

• Maintain reporting tools and dashboards to track overall P&I cost, monitor financial trends, and support cost containment initiatives.
• Develop and maintain dashboards and reports to monitor open vs. closed claims, turnaround times, and financial impact.
• Support monthly financial reporting by compiling expense data, validating entries, and preparing summaries.
• Assist with ad hoc financial analysis, special projects, and operational reviews.

CROSS-FUNCTIONAL SUPPORT & COMPLIANCE

• Partner with Case Management and Health Operations teams to support claims review and financial inquiries.
• Maintain confidentiality of sensitive medical and financial information.
• Support continuous improvement initiatives related to claims workflows, AP processes, and financial reporting.
• Perform other duties as assigned.

Knowledge, Skills & Abilities:

• Scope: The Specialist, Health Claims must demonstrate a solid understanding of health claims processes, accounts payable workflows, and financial documentation standards. The role requires familiarity with medical billing terminology, contracted rate structures, vendor payment requirements, and internal financial controls.
• Problem solving: This role requires the ability to analyze complex claim documentation, identify discrepancies, and determine appropriate corrective actions. The Specialist must evaluate invoice accuracy, validate benefit eligibility, and resolve billing issues by applying established guidelines and financial principles. Problem solving involves interpreting data trends, assessing root causes of payment delays or claim variances, and recommending improvements to enhance cost containment and operational efficiency. The role's decisions directly support financial accuracy, vendor performance, and the integrity of health finance operations.
• Impact: The Specialist, Health Claims directly supports the financial integrity and operational effectiveness of Carnival Corporation's global health ecosystem. By ensuring accurate claims processing, timely vendor payments, and reliable financial reporting, this role helps maintain trust with medical providers, supports crew and guest care continuity, and strengthens the organization's cost ? containment efforts. The Specialist's work contributes to the accuracy of financial data used in enterprise decision ? making, supports compliance with contractual and regulatory requirements, and enhances the efficiency of health finance operations across all brands and regions.
• Leadership: Although this role does not include direct supervisory responsibilities, the Specialist is expected to demonstrate strong cross ? functional leadership through communication, documentation, and operational coordination. The Specialist collaborates with Case Management, Accounts Payable, Population Health, and external vendors, ensuring alignment and timely resolution of financial matters. Effective leadership is shown through ownership of tasks, proactive issue identification, clear communication, and consistent adherence to compliance and service standards. This role contributes to team effectiveness by modeling professionalism, reliability, and strong organizational discipline.

For all roles:

• Knowledge: Understanding of workplace policies and procedures / Familiarity with team collaboration tools and techniques.
• Skills: Strong time management and organizational skills
• Abilities: Ability to maintain reliable and consistent attendance / Capacity to be punctual and meet deadlines / Ability to collaborate effectively with colleagues and work as part of a team / Demonstrated professionalism in all interactions and tasks.

Essential/Minimum qualifications:

• Bachelor's degree in Business, Finance, Accounting, or Healthcare Administration.
• Certified Professional Biller (CPB) or similar medical billing and coding credential (e.g., CMRS, CBCS) preferred.
• Certification demonstrates competency in medical billing compliance, claims processing, reimbursement methodologies, and payer requirements.

Essential experience required:

• 2+ years of experience in healthcare finance, claims processing, medical billing, AP, or related field.
• Experience with medical claims, billing codes, or vendor payment systems preferred.
• Experience with Excel, Power BI, PowerApps, or other financial/claims systems preferred.

Travel : No or very little travel likely

Work Conditions: Work primarily in a climate-controlled environment with minimal safety/health hazard potential.

Physical Demands : Must be able to remain in a stationary position at a desk and/or computer for extended periods of time.

This position is classified as "in-office." As an in-office role, it requires employees to work from a designated Carnival office in South Florida Monday through Thursday each week. Employees may work from their homes on Fridays. Candidates must be located in (or willing to relocate to) the Miami/Ft. Lauderdale area.

Offers to selected candidates will be made on a fair and equitable basis, taking into account specific job-related skills and experience.

At Carnival, your total rewards package is much more than your base salary. All non-sales roles participate in an annual cash bonus program, while sales roles have an incentive plan. Director and above roles may also be eligible to participate in Carnival's discretionary equity incentive plan. Plus, Carnival provides comprehensive and innovative benefits to meet your needs, including:

• Health Benefits:
  • Cost-effective medical, dental and vision plans
  • Employee Assistance Program and other mental health resources
  • Additional programs include company paid term life insurance and disability coverage
• Financial Benefits:
  • 401(k) plan that includes a company match
  • Employee Stock Purchase plan
• Paid Time Off
  • Holidays All full-time and part-time with benefits employees receive days off for 8 company-wide holidays, plus 2 additional floating holidays to be taken at the employee's discretion.
  • Vacation Time All full-time employees at the manager and below level start with 14 days/year; director and above level start with 19 days/year. Part-time with benefits employees receive time off based on the number of hours they work, with a minimum of 84 hours/year.